scholarly journals Fluid management and deresuscitation practices: A survey of critical care physicians

2019 ◽  
Vol 21 (2) ◽  
pp. 111-118 ◽  
Author(s):  
Jonathan A Silversides ◽  
Daniel F McAuley ◽  
Bronagh Blackwood ◽  
Eddy Fan ◽  
Andrew J Ferguson ◽  
...  
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Fluid Overload ◽  
Fluid Management ◽  
Randomised Trial ◽  
Strong Support ◽  
Adverse Outcomes ◽  
Randomised Trials ◽  
Surgical Intensive Care ◽  
Overall Acceptability

Accumulation of a positive fluid balance is common in critically ill patients, and is associated with adverse outcomes, including mortality. However, there are few randomised clinical trials to guide clinicians as to the most appropriate fluid strategy following initial resuscitation and on the use of deresuscitation (removal of accumulated fluid using diuretics and/or renal replacement therapy). To inform the design of randomised trials, we surveyed critical care physicians with regard to perceptions of fluid overload in critical care, self-reported practice, acceptability of a variety of approaches to deresuscitation, appropriate safety parameters, and overall acceptability of a randomised trial of deresuscitation. Of 524 critical care specialists completing the survey, the majority practiced in mixed medical/surgical intensive care units in the United Kingdom. Most (309 of 363 respondents, 85%) believed fluid overload to be a modifiable source of morbidity; there was strong support (395 of 457, 86%) for a randomised trial of deresuscitation in critical illness. Marked practice variability was evident among respondents. In a given clinical scenario, self-reported practice ranged from the administration of fluid (N = 59, 14%) to the administration of a diuretic (N = 285, 67%). The majority (95%) considered it appropriate to administer diuretics for fluid overload in the setting of noradrenaline infusion and to continue to administer diuretics despite mild dysnatraemias, hypotension, metabolic alkalosis, and hypokalaemia. The majority of critical care physicians view fluid overload as a common and modifiable source of morbidity; deresuscitation is widely practiced, and there is widespread support for randomised trials of deresuscitation in critical illness.

scholarly journals Fluid Management In Patients With Chronic Heart Failure

2015 ◽  
Vol 1 (2) ◽  
pp. 90 ◽  
Author(s):  
Pierpaolo Pellicori ◽  
Kuldeep Kaur ◽  
Andrew L Clark ◽  
◽  
◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Fluid Overload ◽  
Adverse Outcome ◽  
Fluid Management ◽  
Objective Measures ◽  
Clinical Feature ◽  
Robust Method ◽  
Randomised Trials ◽  
Heart Failure Patients

Congestion, or fluid overload, is a classic clinical feature of patients presenting with heart failure patients, and its presence is associated with adverse outcome. However, congestion is not always clinically evident, and more objective measures of congestion than simple clinical examination may be helpful. Although diuretics are the mainstay of treatment for congestion, no randomised trials have shown the effects of diuretics on mortality in chronic heart failure patients. Furthermore, appropriate titration of diuretics in this population is unclear. Research is required to determine whether a robust method of detecting — and then treating — subclinical congestion improves outcomes.

scholarly journals Could Exogenous Insulin Ameliorate the Metabolic Dysfunction Induced by Glucocorticoids and COVID-19?

2021 ◽  
Vol 12 ◽  
Author(s):  
Martin Brunel Whyte ◽  
Prashanth R. J. Vas ◽  
Anne M. Umpleby
Keyword(s):  
Critical Care ◽  
Critical Illness ◽  
Adverse Outcomes ◽  
High Dose ◽  
Metabolic Dysfunction ◽  
Consistent Finding ◽  
High Dose Dexamethasone ◽  
Catabolic State ◽  
Coronavirus Infection ◽  
Obesity Hypertension

The finding that high-dose dexamethasone improves survival in those requiring critical care due to COVID-19 will mean much greater usage of glucocorticoids in the subsequent waves of coronavirus infection. Furthermore, the consistent finding of adverse outcomes from COVID-19 in individuals with obesity, hypertension and diabetes has focussed attention on the metabolic dysfunction that may arise with critical illness. The SARS coronavirus itself may promote relative insulin deficiency, ketogenesis and hyperglycaemia in susceptible individuals. In conjunction with prolonged critical care, these components will promote a catabolic state. Insulin infusion is the mainstay of therapy for treatment of hyperglycaemia in acute illness but what is the effect of insulin on the admixture of glucocorticoids and COVID-19? This article reviews the evidence for the effect of insulin on clinical outcomes and intermediary metabolism in critical illness.

scholarly journals Adverse Outcomes due to Aggressive Fluid Resuscitation in Children: A Prospective Observational Study

2018 ◽  
Vol 08 (02) ◽  
pp. 064-070 ◽  
Author(s):  
Anand Muttath ◽  
Lalitha Annayappa Venkatesh ◽  
Joe Jose ◽  
Anil Vasudevan ◽  
Santu Ghosh
Keyword(s):  
Observational Study ◽  
Critically Ill ◽  
Prospective Observational Study ◽  
Fluid Overload ◽  
Fluid Management ◽  
Oxygenation Index ◽  
Adverse Outcomes ◽  
Critically Ill Children ◽  
Mortality And Morbidity ◽  
The Impact

AbstractFluid management has a major impact on the duration, severity, and outcome of critically ill children. The aim of this study was to examine the relationship between cumulative fluid overload (CFO) with mortality and morbidity in critically ill children. This was a prospective observational study wherein children (1 month–16 years) who were critically ill (with shock requiring inotropes and/or mechanically ventilated) were enrolled. CFO was defined as the sum of daily fluid balances. Daily fluid balance was calculated as a difference between fluid intake (oral and intravenous) and output (urine output, discharge from nasogastric tube) in 24 hours. Percentage of fluid overload (FO) (PFO) was calculated as the ratio of CFO with weight at admission in kilogram. The CFO and PFO at 24, 48, 72 hours and at 7 days or end of PICU stay were calculated. A total of 291 children (244 survivors and 47 non-survivors; 47% males) were included in the final analysis. A higher mortality was observed in children with higher PFO (>20% FO: 45.8% mortality vs. 14.5% < 10% FO, p < 0.01) and CFO (10.97 ± 6.4 mL/kg in survivors vs. 13.95 ± 9.6 mL/kg in non-survivors; p = 0.022) at 72 hours. A 1% increase in fluid overload was associated with 6% and 4% increase in mortality at 72 hours and 7 days, respectively. Similarly, the impact of every 1% increase in fluid overload on both ventilation (yes/no) and acute kidney injury (AKI; yes/no) were found to be significant for both parameters at 72 hours, but only AKI had significant correlation on seventh day. In the multivariate stepwise Cox's proportional hazard model for PICU stay and hospital stay, 3% (p < 0.05) and 2% (p > 0.05) increase were found for every 1% increase in fluid overload, respectively. Oxygenation index is also associated with fluid overload with the adjusted model estimated 0.27 units (95% confidence interval: 0.18–0.36) increase per 1% increase in fluid overload. FO was associated with increased mortality and morbidity in critically ill children.

scholarly journals Adaptive metabolic and inflammatory responses identified using accelerated aging metrics are linked to adverse outcomes in severe SARS-CoV-2 infection

2021 ◽  
Author(s):  
Alejandro Márquez-Salinas ◽  
Carlos A Fermín-Martínez ◽  
Neftalí Eduardo Antonio-Villa ◽  
Arsenio Vargas-Vázquez ◽  
Enrique C. Guerra ◽  
...  
Keyword(s):  
Critical Illness ◽  
Proportional Hazards ◽  
Inflammatory Responses ◽  
Age Groups ◽  
Accelerated Aging ◽  
Cox Proportional Hazards ◽  
Adverse Outcomes ◽  
Adaptive Responses ◽  
Predictive Capacity ◽  
Risk Of Death

Abstract Background Chronological age (CA) is a predictor of adverse COVID-19 outcomes; however, CA alone does not capture individual responses to SARS-CoV-2 infection. Here, we evaluated the influence of aging metrics PhenoAge and PhenoAgeAccel to predict adverse COVID-19 outcomes. Furthermore, we sought to model adaptive metabolic and inflammatory responses to severe SARS-CoV-2 infection using individual PhenoAge components. Methods In this retrospective cohort study, we assessed cases admitted to a COVID-19 reference center in Mexico City. PhenoAge and PhenoAgeAccel were estimated using laboratory values at admission. Cox proportional hazards models were fitted to estimate risk for COVID-19 lethality and adverse outcomes (ICU admission, intubation, or death). To explore reproducible patterns which model adaptive responses to SARS-CoV-2 infection, we used k-means clustering using PhenoAge components. Results We included 1068 subjects of whom 222 presented critical illness and 218 died. PhenoAge was a better predictor of adverse outcomes and lethality compared to CA and SpO2 and its predictive capacity was sustained for all age groups. Patients with responses associated to PhenoAgeAccel&gt;0 had higher risk of death and critical illness compared to those with lower values (log-rank p&lt;0.001). Using unsupervised clustering we identified four adaptive responses to SARS-CoV-2 infection: 1) Inflammaging associated with CA, 2) metabolic dysfunction associated with cardio-metabolic comorbidities, 3) unfavorable hematological response, and 4) response associated with favorable outcomes. Conclusions Adaptive responses related to accelerated aging metrics are linked to adverse COVID-19 outcomes and have unique and distinguishable features. PhenoAge is a better predictor of adverse outcomes compared to CA.

scholarly journals Individualized Hemodynamic Management in Sepsis

2021 ◽  
Vol 11 (2) ◽  
pp. 157
Author(s):  
Marcell Virág ◽  
Tamas Leiner ◽  
Mate Rottler ◽  
Klementina Ocskay ◽  
Zsolt Molnar
Keyword(s):  
Fluid Overload ◽  
Fluid Management ◽  
Multiple Organ ◽  
Treatment Protocols ◽  
Hemodynamic Management ◽  
New Approach ◽  
Hemodynamic Optimization ◽  
The Individual ◽  
Sepsis And Septic Shock ◽  
Insight Into

Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and “restrictive” infusion strategies have been recommended by guidelines over “liberal” approaches for several years. Unfortunately, these “fixed regimen” treatment protocols neglect the patient’s individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.

scholarly journals The Impact of Changing to an Algorithm-Based Clostridioides difficile Test on the Decision to Treat Clostridioides difficile

2020 ◽  
Vol 41 (S1) ◽  
pp. s407-s407
Author(s):  
Lana Dbeibo ◽  
Joy Williams ◽  
Josh Sadowski ◽  
William Fadel ◽  
Vera Winn ◽  
...  
Keyword(s):  
Critical Care ◽  
Toxic Megacolon ◽  
Adverse Outcomes ◽  
Clinical Criteria ◽  
Testing Method ◽  
Clostridioides Difficile ◽  
Critical Care Admission ◽  
The Impact ◽  
Test Result ◽  
Pcr Test

Background: Polymerase chain reaction (PCR) testing for the diagnosis of Clostridioides difficile infection (CDI) detects the presence of the organism; a positive result therefore cannot differentiate between colonization and the pathogenic presence of the bacterium. This may result in overdiagnosis, overtreatment, and risking disruption of microbial flora, which may perpetuate the CDI cycle. Algorithm-based testing offers an advantage over PCR testing as it detects toxin, which allows differentiation between colonization and infection. Although previous studies have demonstrated the clinical utility of this testing algorithm in differentiating infection from colonization, it is unknown whether the test changes CDI treatment decisions. Our facility switched from PCR to an algorithm-based testing method for CDI in June 2018. Objective: In this study, we evaluated whether clinicians’ decisions to treat patients are impacted by a test result that implies colonization (GDH+/Tox−/PCR+ test), and we examined the impact of this decision on patient outcomes. Methods: This is a retrospective cohort study of inpatients with a positive C. diff test between June 2017 and June 2019. The primary outcome was the proportion of patients treated for CDI. We compared this outcome in 3 groups of patients: those with a positive PCR test (June 2017–June 2018), those who had a GDH+/Tox−/PCR+ or a GDH+/Tox+ test result (June 2018–June 2019). Secondary outcomes included toxic megacolon, critical care admission, and mortality in patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated. Results: Of patients with a positive PCR test, 86% were treated with CDI-specific antibiotics, whereas 70.4% with GDH+/Tox+ and 29.25% with GDH+/Tox−/PCR+ result were treated (P < .0001). Mortality was not different between patients with GDH+/Tox−/PCR+ who were treated versus those who were untreated (2.7% vs 3.4%; P = .12), neither was critical care admission within 2 or 7 days of test result (2% vs 1.4%; P = .15) and (4.1% vs 5.4%, P = .39), respectively. There were no cases of toxic megacolon during the study period. Conclusions: The change to an algorithm-based C. difficile testing method had a significant impact on the clinicians’ decisions to treat patients with a positive test, as most patients with a GDH+/Tox−/PCR+ result did not receive treatment. These patients did not suffer more adverse outcomes compared to those who were treated, which has implications for testing practices. It remains to be explored whether clinicians are using clinical criteria to decide whether or not to treat patients with a positive algorithm-based test, as opposed to the more reflexive treatment of patients with a positive PCR test.Funding: NoneDisclosures: None

scholarly journals PREPARE: protocol for a stepped wedge trial to evaluate whether a risk stratification model can reduce preterm deliveries among women with suspected or confirmed preterm pre-eclampsia

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Marcos Augusto Bastos Dias ◽  
◽  
Leandro De Oliveira ◽  
Arundhanthi Jeyabalan ◽  
Beth Payne ◽  
...  
Keyword(s):  
Knowledge Transfer ◽  
Adverse Events ◽  
Risk Stratification ◽  
Risk Reduction ◽  
Randomised Trial ◽  
Adverse Outcomes ◽  
Cluster Randomised Trial ◽  
Care Providers ◽  
Stepped Wedge ◽  
Number Of Patients

Abstract Background Preeclampsia (PE) is a major cause of short and long-term morbidity for affected infants, including consequences of fetal growth restriction and iatrogenic prematurity. In Brazil, this is a special problem as PE accounts for 18% of preterm births (PTB). In the PREPARE (Prematurity REduction by Pre-eclampsia cARE) study, we will test a novel system of integrated care based on risk stratification and knowledge transfer, to safely reduce PTB. Methods This is a stepped wedge cluster randomised trial that will include women with suspected or confirmed PE between 20 + 0 and 36 + 6 gestational weeks. All pregnant women presenting with these findings at seven tertiary centres in geographically dispersed sites, throughout Brazil, will be considered eligible and evaluated in terms of risk stratification at admission. At randomly allocated time points, sites will transition to risk stratification performed according to sFlt-1/PlGF (Roche Diagnostics) measurement and fullPIERS score with both results will be revealed to care providers. The healthcare providers of women stratified as low risk for adverse outcomes (sFlt-1/PlGF ≤38 AND fullPIERS< 10% risk) will receive the recommendation to defer delivery. sFlt-1/PlGF will be repeated once and fullPIERS score twice a week. Rates of prematurity due to preeclampsia before and after the intervention will be compared. Additionally, providers will receive an active program of knowledge transfer about WHO recommendations for preeclampsia, including recommendations regarding antenatal corticosteroids for foetal benefits, antihypertensive therapy and magnesium sulphate for seizure prophylaxis. This study will have 90% power to detect a reduction in PTB associated with PE from a population estimate of 1.5 to 1.0%, representing a 33% risk reduction, and 80% power to detect a reduction from 2.0 to 1.5% (25% risk reduction). The necessary number of patients recruited to achieve these results is 750. Adverse events, serious adverse events, both anticipated and unanticipated will be recorded. Discussion The PREPARE intervention expects to reduce PTB and improve care of women with PE without significant adverse side effects. If successful, this novel pathway of care is designed for rapid translation to healthcare throughout Brazil and may be transferrable to other low and middle income countries. Trial registration ClinicalTrials.gov: NCT03073317.

Advances in critical care for the older patient

2013 ◽  
Vol 23 (2) ◽  
pp. 118-130 ◽  
Author(s):  
Diane Monkhouse
Keyword(s):  
Quality Of Life ◽  
Critical Care ◽  
Critical Illness ◽  
General Population ◽  
Acute Illness ◽  
Limited Resources ◽  
Care Practice ◽  
Older Patient ◽  
Life Sustaining Treatment

SummaryAs the proportion of elderly people in the general population increases, so does the number admitted to critical care. In caring for an older patient, the intensivist has to balance the complexities of an acute illness, pre-existing co-morbidities and patient preference for life-sustaining treatment with the chances of survival, quality of life after critical illness and rationing of expensive, limited resources. This remains one of the most challenging areas of critical care practice.

scholarly journals Association Between Room Location and Adverse Outcomes in Hospitalized Patients

2018 ◽  
Vol 12 (2) ◽  
pp. 21-29 ◽  
Author(s):  
Anoop Mayampurath ◽  
Christopher Ward ◽  
John Fahrenbach ◽  
Cynthia LaFond ◽  
Michael Howell ◽  
...  
Keyword(s):  
Critical Illness ◽  
Severity Of Illness ◽  
Adverse Outcomes ◽  
Sensitivity Analyses ◽  
Additional Risk Factor ◽  
Inhospital Mortality ◽  
Additional Risk ◽  
Increased Risk ◽  
Euclidean Distances ◽  
Time Of Admission

Objective: To investigate whether a patient’s proximity to the nurse’s station or ward entrance at time of admission was associated with increased risk of adverse outcomes. Method: We conducted a retrospective cohort study of consecutive adult inpatients to 13 medical–surgical wards at an academic hospital from 2009 to 2013. Proximity of admission room to the nurse’s station and to the ward entrance was measured using Euclidean distances. Outcomes of interest include development of critical illness (defined as cardiac arrests or transfer to an intensive care unit), inhospital mortality, and increase in length of stay (LOS). Results: Of the 83,635 admissions, 4,129 developed critical illness and 1,316 died. The median LOS was 3 days. After adjusting for admission severity of illness, ward, shift, and year, we found no relationship between proximity at admission to nurse’s station our outcomes. However, patients admitted to end of the ward had higher risk of developing critical illness (odds ratio [ OR] = 1.15, 95% confidence interval [CI] = [1.08, 1.23]), mortality ( OR = 1.16, 95% CI [1.03, 1.33]), and a higher LOS (13-hr increase, 95% CI [10, 15] hours) compared to patients admitted closer to the ward entrance. Similar results were observed in sensitivity analyses adjusting for isolation room patients and considering patients without room transfers in the first 48 hr. Conclusions: Our study suggests that being away from the nurse’s station did not increase the risk of these adverse events in ward patients, but being farther from the ward entrance was associated with increase in risk of adverse outcomes. Patient safety can be improved by recognizing this additional risk factor.

Sign in / Sign up

Export Citation Format

Share Document